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Root Cause Analysis Training for HCAI. Session 1 Welcome and Introductions. RCA for HCAI Programme. Session 2 RCA Setting it in context An introduction to RCA. RCA – Introduction & Context. What is it?

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Root Cause Analysis Training for HCAI


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    Presentation Transcript
    1. Root Cause Analysis Training for HCAI

    2. Session 1 Welcome and Introductions

    3. RCA for HCAI Programme

    4. Session 2 RCA Setting it in context An introduction to RCA

    5. RCA – Introduction & Context What is it? • A retrospective review of a service user safety incident undertaken in order to identify what, how, and why it happened • A process of investigation and analysis is then used to identify areas for improvement. • Finally recommendations and sustainable solutions are agreed to minimise the recurrenceof the incident type in the future.

    6. RCA: Introduction and Context When should RCA be undertaken for HCAI?

    7. When should RCA be undertaken for HCAI? • All MRSA bacteraemia • Local consideration to CDI cases that may include: • CDI Deaths • End stage disease e.g. colectomy • Outbreaks • Cluster • Other infections as per local policy

    8. Benefits of RCA for HCAI?

    9. Benefits of RCA ? Service User • Reduced risk of infection, increased safety and quality of care • Improved service user choice • Increased Public confidence Providers of Care • Improved quality and safety, focus on risks and contributory factors, ability to target resources, improved service user pathways, increased service user confidence, shared learning • Reduced length of stay • Reduced litigation • Improved staff moral Commissioners of care • Improved assurance, governance, education, communication, clinical practice, shared learning • Improved ability to commission quality care National • Reduced infection rates, reduced political focus, development of tools and guidance, • increased public confidence

    10. Session 3 RCA Process

    11. A Clear Process for HCAI React • Identify immediate care needs • Commence treatment and management of bacteraemia • Identify any obvious problems and take action Record • Gather data • Map the patient’s journey • Arrange RCA review meeting to identify problems, contributory factors and root causes • Agree action plan Respond • Deliver action plan • Monitor action plan delivery and impact • Identify & act upon organisational themes and trends

    12. RCA for HCAI: Best Practice Process • Organisations encouraged to perform gap analysis against process • Aiming to embed HCAI prevention into everyday culture • Guidelines intended as a benchmark for local interpretation and action to improve on their existing process rather than replace it

    13. Process

    14. Session 4 Root Cause Analysis Data Gathering Tools

    15. MRSA Data Gathering Tool

    16. How to use the tool • RCA Lead completes the data gathering tool prior to the formal RCA review meeting • The tool is sent to participants in advance of RCA review meeting • RCA Lead maps the data to aid analysis at the review meeting

    17. Session 5 Role of the RCA review team

    18. Purpose of the RCA Review

    19. Purpose of the RCA Review • Analyse the data gathered • Identify problems in the care pathway • Identify contributory factors • Identify root cause • Identify actions to prevent recurrence

    20. RCA Review Who should be involved ?

    21. Who should be involved ? Core Team • RCA Lead • Executive lead • DIPC • Microbiologist / Infection Control Doctor • Infection Control Practitioner • Admin Support • Risk/Performance Manager • Matron / Senior Nurse Care setting representatives • Doctor responsible for management of patient • Nurse responsible for care of patient • Others as appropriate

    22. Validate the data • Review RCA paperwork in advance of meeting • Contribute to the discussions to validate the information and data • Challenge assumptions • Analyse the information • Contribute to analysis of human and other contributory factors • Analyse underlying systems and processes through a series of ‘why’ questions Roles and Responsibilities Of The RCA Review Team • Learning the Lessons • Communicate findings through local staff bulletins and team meetings • Demonstrate leadership and recognition of the seriousness of HCAIs to all clinical staff • Ensure outcomes and actions are implemented • Escalate unresolved issues to management team • Educate staff to ensure new practices are sustained • Develop an action plan • Provide an ‘expert’ contribution to the validation of the key issues/ emerging findings • Make recommendations and agree actions that relate to the most fundamental cause(s)

    23. Verifying the data • RCA Lead checks the findings from the initial data collection exercise to ensure there are no gaps and all unconfirmed data has been confirmed • RCA Lead presents the findings in a logical order to the group • RCA team identifies the key issues/problems within the findings • Using a process of brainstorming: • Capture initial thoughts of the team • Prioritise in order of importance • Asking the right question is at the heart of effective RCA process • This will help to ensure you gather useful information and learn more

    24. Identifying Problems Simple definition Something happened that should not have happened…… …..or something should have happened, but didn’t.

    25. Describing your problems To effectively analyse problems, a specific description of what happened is required: Be specific not vague: • Communication failure = X • Nurse failed to inform doctor of wound condition = OK Identify what happened not why: • Inadequate training on hand hygiene = X • SHO did not wash or decontaminate his hands = OK

    26. Analysis of findings Once the problems have been identified the review team needs to: • Analyse the key issues/problems • Drill down to unearth the contributory factors and ultimately the root causes • Reach agreement on the root cause • Use tools such as ‘Five Whys’ and the cause and effect diagrams to help explore the contributory factors of each problem • Tools are designed to encourage more in-depth analysis at each level of cause and effect

    27. ‘Five Whys’ Technique Nurse failed to undertake MRSA screening on admission Why? She was not aware this was a requirement for emergency admissions This was not covered in her orientation to the MAU Why? Why? IP&C was not included in the induction training for new starters Why? No Registered Provider wide approach to ward induction programmes Root Cause

    28. Identify Root Cause(s) What is a Root Cause? A fundamental contributory factor which, if resolved, will reduce the likelihood of recurrence of the identified problem. • There may be more than one root cause and therefore the RCA team must identify the contributory factors which have the greatest impact on each problem. • Using the ‘Five whys’ technique will help identify the most significant contributory factors.

    29. Confirming action plan and follow through • Chair will lead the discussion on identifying actions to be undertaken to: • Address the root causes • Highlight the outputs of each action • Outline the timescales for delivery • Identify the responsible owner • Decide what can be done to prevent the problem happening again • Explore how the solution will be implemented • Agree who will be responsible/accountable • Agree what are the risks of implementing the solution

    30. Session 6 Analysis

    31. Analysis • Who needs to be present at the review meeting ? • Is there any data missing?

    32. RCA Lead Consultant in charge of patient Matron/s Ward Managers Junior Doctors ICN Microbiologist Pharmacist Locality Manager District Nurse/s PCT Manager GP Participants at the review meeting?

    33. Is there any data missing? • Community screening policy • A&E record • Staff training records - PCT • Staffing levels • Process for blood culture taking • Bed management data • side room use and time to isolation

    34. Group Activity Discuss and Identify: • Problems • Risks to Other Patients • Contributory Factors • Root Causes

    35. Findings – Pre Hospital

    36. Findings – Pre Hospital

    37. Other factors – Pre Hospital

    38. Delayed diagnosis of MRSA – Hospital

    39. RCA Review What are the root causes?

    40. Session 7 Summary

    41. RCA for HCAI Further Reading • Towards Cleaner Hospitals and Lower Rates of Infection • 7 Steps to service user Safety • Anderson, Bjorn & Fagerhaug, et al (2000) Root Cause Analysis Simplified Tools 7 Techniques ASQ Quality Press. • National Confidential Study of Deaths Following Meticillin-Resistant Staphylococcus aureus Infection. London: Health Protection Agency, November 2007 Useful Websites: • http://www.hpa.org.uk • http://www.npsa.nhs.uk • http://www.dh.gov.uk